Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Friday, May 19, 2017

Will the Current Crises Finally Prompt America to Address How it is Haunted by Corruption and Impunity?

There is one tiny silver lining in the political storm clouds swirling over the US. Some of the issues about which we have been ranting on Health Care Renewal are no longer so easily dismissed. We have long harangued about the ruinous effects of health care corruption, the role of impunity in enabling worsening corruption, our lack of good ways to challenge these problems, and our ongoing inablity to even discuss what amounts to taboo topics (which we dubbed the "anechoic effect.") In response, we have been called alarmists, nay-sayers, and worse. Now the parade of crises created by the Trump regime have made these problems salient to American society.

Corruption is a Huge Problem and We are Ill-Equipped to Deal With It

We have frequently discussed outright corruption in health care as one of the most important causes of health care dysfunction. Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report
on health care corruption, which asserted that corruption is widespread
throughout the world, serious, and causes severe harm to patients and
society.

the scale of corruption is vast in both rich and poor countries.

Also,

Corruption might mean the difference between life and death for
those in need of urgent care. It is invariably the poor in society who
are affected most by corruption because they often cannot afford bribes
or private health care. But corruption in the richest parts of the world
also has its costs.

The report did not get much attention. Since then, health care corruption
has been nearly a taboo topic in the US. When health care corruption
is discussed in English speaking developed countries, it is almost
always in terms of a problem that affects benighted less developed
countries. On Health Care Renewal,
we have repeatedly asserted that health care corruption is a big
problem in all countries, including the US. But even after Pope Francis decried health care corruption, the topic remained anechoic.

Yet somehow, a substantial minority of US citizens, 43%, seemed to
believe that corruption is an important problem in US health care,
according to a TI survey published in 2013 (look here).
But that survey was largely ignored in the media and health care and
medical scholarly literature in the developed world, and when it was
discussed, it was again in terms of results in less developed
countries. Health Care Renewal was practically the only source of coverage in the US of the survey's results.

Designing investigations into high-level misconduct is extremely difficult. Every nation has tough choices to make, and none has come up with a perfect solution — though it’s clear that the US system is uniquely bad.

The author noted that the US Constitution provides no clear mechanisms for addressing corruption, and in their absence, at best "we'ver jerry-rigged things instead."

So it is good that there is now some minimal public recognition that we in the US have not developed an effective approach to corruption. The unasked question, of course, is why not. Just becauses our constitution is more than 200 years old is not really an excuse. Constitutions can be amended and laws can be written. I submit that we have been in a long-standing state of denial about the existence of corruption, based perhaps on an erroneous conception of American exceptionalism, and enabled by those who have gotten rich off corruption, and for a long time have been using substantial resources to keep the problem anechoic.

Now we pay the penalty for our perhaps wilfull ignorance.

Impunity Enables Worsening Behavior

We have long railed against the impunity of top leaders in health care. We have gone on ad infinitum about the parade of legal settlements made by large health care organizations after allegations of often egregious misbehavior, including episodes of bribery, fraud,kickbacks, and other crimes. Typically, such settlements allowed the organizations to walk away after paying a monetary penalty that may have appeared big, but was tiny compared to the monay that could have been made from the misbehavior. In particular, almost never does anyone at the organizations who authorized or directed the bad behavior, particularly top executives, suffer any negative consequences at all, even when they may have made huge bonuses because of the revenues such behavior generated. The continuing impunity of top health care leaders only seems to encourage future bad behavior.

Its author, Matthew Yglesias, indicted President Trump as a long time beneficiary of impunity, whose behavior was enabled by impunity, and who is thus typical of American corporate leaders.

He’s a man who’s learned over the course of a long and
rich life that he is free to operate without consequence. He’s the
beneficiary of vast and enormous privilege, not just the ability to
enjoy lavish consumption goods but the privilege of impunity that
America grants to the wealthy.

Trump’s 'law and order' attorney general wants to throw
the book at relatively small-time drug offenders. Trump himself has
spent his entire career skating away from lawbreaking with a fine paid
here and a political contribution there. He’s an unusual figure, but
also very much an exemplar of his era and a product of a decades-long
ideological campaign to do as much as possible to empower the wealthy
and powerful.

His entire adult life, Trump has been able dodge legal trouble simply
by using his bank account as a shield. When Trump Management was sued
by the government in 1973 for refusing to rent apartments to people of
color, Trump and his father were able to settle without any admission of
guilt. When students at Trump University sued him for defrauding them,
Trump simply wrote a check for $25 million to make it all go away.

Marriage in the tank? He's got a pre-nup. Casino business going belly-up? He goes to bankruptcy court, walks away, and writes another book praising his own genius.

Trump's Impunity is the Current Vivid Case of a Problem of Historic Proportions

Trump's current actions are, per Mr Yglesias,

entirely emblematic of America’s post-Reagan treatment of
business regulation. What a wealthy and powerful person faced with a
legal impediment to moneymaking is supposed to do is work with a lawyer
to devise clever means of subverting the purpose of the law. If you end
up getting caught, the attempted subversion will be construed as a
mitigating (it’s a gray area!) rather than aggravating factor. Your
punishment will probably be light and will certainly not involve anything more than money. You already have plenty of money, and your plan is to get even more. So why not?

I might quibble that the US problem with corruption and impunity goes back years before President Reagan's administration. However, still

beyond Trump, America is desperately in need of a larger political reckoning as well.

The entire culture of civil fines and settlements without
admission of wrongdoing that dominates American business regulation is
fundamentally odd. If the rules say you can’t keep your casino afloat
with an unapproved loan and you respond to that by getting a shady secret unapproved loan
to keep your casino afloat, shouldn’t you be out of the casino game? If
compliance with money laundering rules is mandatory and you don’t
comply, shouldn’t you be shut down?

Any given case obviously presents its nuances, and not
every case can be taken to the mattresses. But the settlement racket too
easily lets regulators feel like they’re putting points on the board
even while criminals continue to roam the streets, having learned the
lesson that they’re untouchable. That, fundamentally, is Trump’s
problem. Not that he can’t control himself, but that he’s been taught he
doesn’t have to.

Summary

Sometimes crises do illuminate long festering problems. If the US survives the current serial crises, maybe we will be able to develop a more open, rational and effective approach to corruption and impunity, including their health care variants.

So to repeat an ending to one of my previous posts
on health care corruption.... if we really want to reform health care,
in the little time we may have
before our health care bubble bursts, we will need to take strong action
against health care corruption. Such action will really disturb the
insiders within large health care organizations who have gotten rich
from their organizations' misbehavior, and thus taking such action will
require some courage. Yet such action cannot begin until we acknowledge
and freely discuss the problem. The first step against health care
corruption is to be able to say or write the words, health care
corruption.

2 comments:

Anonymous
said...

The impunity of stars starts in high school. The quarterback of the winning high school football team is able to abuse drugs and commit sexual assault without suffering the consequences. Star college athletes have the same kind of impunity. A winning coach could get away with pedophilia for years and have supporters protesting in his favor when he is held accountable. Its as American as mom and apple pie.

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